MEDICARE: KENNETH A. BUNDZA AND SHERWIN Y. KEPES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	20010117A	IN
2	103T00000X	Psychologist	20010242A	IN

General Provider Information

NPI Number	:	1942369194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH A. BUNDZA AND SHERWIN Y. KEPES

Provider Business Mailing Address
First Line	:	6026 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7639
Country	:	US
Telephone Number	:	260-749-8419
Fax Number	:	260-749-0553

Provider Business Practice Location Address
First Line	:	6026 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7639
Country	:	US
Telephone Number	:	260-749-8419
Fax Number	:	260-749-0553

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. KENNETH A. BUNDZA
Credential	:	PH.D.
Telephone Number	:	260-749-8419

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	08/22/2020

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